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Needles not sex drove African AIDS pandemic

The re-use of dirty needles in healthcare – not promiscuity – was the main cause of the AIDS pandemic now devastating Africa, according to a controversial new analysis.

It challenges the assumption, dating from 1988, that unsafe heterosexual sex accounted for 90 per cent of HIV transmissions in Africa.

“We’ve gathered all the literature we can on AIDS in Africa and the best we can estimate, for sexual transmission, is a quarter to a third,” says David Gisselquist, an independent anthropologist from Hershey, Pennsylvania, who led the new study.

Dirty needles accounted for almost half of all cases, the re-analysis of research concludes. The work is published as a three-paper set in the International Journal of STD & AIDS.

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Thirty million people are estimated to be living with HIV in Africa, and 2.5 million died in 2002. Tackling the pandemic requires knowledge of how the virus is being transmitted now, so emphasis can be placed on, say, safe sex education programmes or provision of single-use needles.

“But no one has looked at this for a long time, or with the appropriate data,” acknowledges Yvan Hutin, a specialist on HIV transmission at the World Health Organization in Geneva. “There isn’t any solid data.”

Frightened away

However, Hutin disputes the specific conclusions of the new analysis. “We estimate that dirty needles account for five per cent of cases worldwide, but with large variation.”

Agencies managing international AIDS programmes fear that Africans could be frightened away from visiting clinics for vital immunisations. “The other worry is that it might encourage complacency in sex,” says Catherine Hankins, chief scientific adviser for UNAIDS in Geneva.

Other experts point out that hepatitis B, which is more easily transmitted via unsterilised needles than HIV, has not spread as rapidly.

But Gisselquist says that with their mindsets fixed on the sexual explanation, researchers have ignored obvious discrepancies. He says the data contradict the idea that Africans are unusually promiscuous, or engage more readily than anyone else in unsafe sex.

Faithful partners

For example, in a 1987-88 study of factory and bank workers in Kinshasa, Congo, the huge majority of with HIV-positive subjects said they had contracted the virus despite being faithful to their partners.

“Although some may have underreported numbers of partners, the consistency of the evidence suggests a large majority of HIV infections in non-promiscuous adults,” he says.

Gisselquist believes the role of prostitution has been overstated. In Zimbabwe during the 1990s, he says, an increase in HIV of 12 per cent coincided with a decrease of 25 per cent in the spread of sexually transmitted diseases (STDs) generally.

He also cites studies suggesting a link to the use of dirty medical needles. One showed that HIV-positive children had an average of 44 injections in their lifetimes, compared with 23 for virus-free children. And in one clinic treating STDs, Gisselquist found that 28 per cent of attendees treated with injections had HIV, compared with 17 per cent who had not had injections.

Despite the disputes, Hankins says&colon; “We all agree that [needle transmission] is so easy to avoid, and all it requires is resources. We definitely want to get to the bottom of it all.” The WHO and UNAIDS have now organised a meeting with Gisselquist in March to discuss his findings.